Saturday, June 28, 2014

Q: 64 year old male with significant past medical history
of end stage congestive heart failure with ejection fraction of 10-15% - awaiting
left ventricular assist device (LVAD) - admitted to ICU with coma. Lab rechecked
and call you with critical value of calcium level of 16.5 mg/dL. On exam,
patient is markedly in anasarca and fluid overload. What is your treatment
option here?

Answer: Hemodialysis

Hemodialysis
with no calcium in the dialysis fluid is an effective therapy for hypercalcemia
in patients where IV hydration is not an option and immediate management is
required. Nephrology service should be consulted to
tailor composition of dialysis solution.

Friday, June 27, 2014

Q: 42 year old female with no significant past medical history except for hypertension, presented to ER with dizziness and palpitations. Initial rhythm showed runs of V.Tach. Only significant description given in history is recent episode of UTI (urinary tract infection) for which she was prescribed antibiotics by an urgent care physician. Which drug interaction is suspected?

Among patients treated with ACEIs or ARBs, the use of Bactrim is associated with a life threatening hyperkalemia, in comparison to other antibiotics. Alternate antibiotic therapy should be considered in such situation.

Thursday, June 26, 2014

Q:52 year old female with ESRD (End
Stage Renal Disease) - on PD (Peritoneal Dialysis) for many years is admitted to
ICU post-op after orthopedic surgery. Patient is requiring fair amount of
narcotics for pain relief. Nurse call you to report outflow problem with her
peritoneal dialysis catheter. What could be the most probable
cause

Answer:Constipation

Constipation in peritoneal dialysis patient is a very
common cause of outflow problem, particularly in patients who have otherwise stabilized catheter (late complication). Use of laxatives to relieve
constipation usually takes care of problem. Obviously, proper physical exam and
other causes should be ruled out.

Wednesday, June 25, 2014

Q:What is the dose of Fentanyl in blunting the sympathetic response to laryngoscopy and intubation?

Answer: 3 mcg/kg

Recommended doses for pretreatment for intubation is 3 mcg/kg to avoid hypotension in patients dependent on sympathetic tone. Fentanyl has been described to cause thoracic and abdominal muscular rigidity but the incidence is extremely low and usually only happens when doses higher than 15 mcg/kg are used.

Sunday, June 22, 2014

Q: How many days usually it takes for Clopidogrel (Plavix) hypersensitivity to manifest?

Answer: About one week

Interestingly, it takes few days before Clopidogrel manifests its hypersensitivity. Usually, it presents as an erythematous, macular, morbilliform rash which usually begins on the face, chest, or abdomen, and slowly spreads to the proximal and then distal extremities. It may even involve palms and soles. It is rarely but can be pruritic. The median time from drug introduction to appearance of symptoms is between 5 and 10 days.

Hypersensitivity can be managed without discontinuation of drug. (see references).

Saturday, June 21, 2014

Q:Beside CSF drainage, what other modality of treatment has shown
some beneficial effect in acute postoperative paraplegia complicating with
emergency graft replacement of the ascending aorta for the Type A
Dissection?

Answer: Hyperbaric Oxygen
(HBO)

Usual dose of oxygen to patient is to
breath 100% oxygen for 90 minutes at a pressure of 2.4 atmospheres
absolute.

Friday, June 20, 2014

Priapism following the infusion of propofol has been reported in literature - which may last for hours. Actual mechanism is not known but various theories has been proposed. It may be secondary to lipid content of the drug causing fat emulsion-related increased thrombin, erythrocyte aggregation and/or fat embolism. Vasodilatation, well know with propofol, has also been speculated as a cause of priapism. Another possibility described is the anesthetic effect in the spinal cord that might have blocked the sympathetic vasoconstrictor action or that might have enhanced the parasympathetic vasodilatory action causing an abnormal erection. Propofol-induced alteration of nitric oxide-mediated smooth muscle relaxation might have also had a contributory effect. The modulating effect on GABAa and adrenal steriodogenesis effects of propofol might have also played an additional role.

Tuesday, June 17, 2014

Q: How strikingly different is pleural effusion finding in
Acute Eosinophilic Pneumonia (AEP)?

Answer:The presence of
eosinophils in the pleural effusion is usually considered nondiagnostic. But if
the pleural fluid is exudative with an increased percentage of eosinophils, AEP
should be strongly considered. It makes diagnosis very susceptible with
hypoxemia, pulmonary infiltrates, eosinophils in bronchoalveolar lavage fluid,
and prompt response to steroid therapy.

Other reasons for
eosinophillia in pleural fluid is previous thoracentesis with air or blood in
contact with the
effusion.

Monday, June 16, 2014

Q: Why it is important recognize Drug rash with eosinophilia and systemic symptoms (DRESS) syndrome?

Answer: The mortality rate associated with DRESS syndrome is approximately 10%, the majority due to fulminant liver failure. It is very important to recognize DRESS Syndrome as treatment is curative with steroids otherwise can be highly fatal.

Sunday, June 15, 2014

A Brief Story of Mannitol

Mannitol remains a standard therapy for reducing intracranial pressure. The initial dose of mannitol is 1 g/kg and can be given emergently without intracranial pressure monitoring as long as the patient is normotensive.

Mannitol is particularly useful if the patient is showing any signs or symptoms of impending herniation. Subsequent dosing to a serum osmolality up to 320 mosm/l is usually recommended as needed. Dosing to higher levels has not been shown to improve outcome and increases the risk of acute renal failure.

Mannitol reduces intracranial pressure through two mechanisms. The immediate mechanism is expansion of intravascular volume which reduces blood viscosity. This results in an increase in cerebral blood flow in the areas of the brain where cerebral autoregulation remains intact and ICP falls. The second mechanism, which occurs later, involves the establishment of osmotic gradients between the serum plasma and the brain cells. This ultimately decreases intracellular volume and reduces intracranial pressure.

Since mannitol also functions as a diuretic there is always a risk of reducing blood pressure and therefore cerebral perfusion pressure if the patient is not adequately volume resuscitated. For this reason, hypertonic saline has gained favor as an osmotic agent for increased ICP since it is less likely to cause hypotension.

Saturday, June 14, 2014

Hepatorenal syndrome is quite common in the cirrhotic population and is found in approximately 10% of individuals admitted to the hospital with ascites.

It is characterized by azotemia, oliguria (500mL per day), low urinary sodium excretion (10mEq per liter), and increased urine-plasma osmolality ratio (U:P 1.0) in the absence of urinary sedimentation.

Histology of renal tissue from patients with hepatorenal syndrome is normal.

Hepatorenal syndrome occurs in patients with pre-existing parenchymal liver disease after a precipitating event such as surgery or a hypotensive episode (e.g., GI bleed, dialysis, sepsis).

The etiology of hepatorenal syndrome is not completely understood but appears to involve vasodilation, decreased effective arterial volume, and further reduction of glomerular filtration by the reninangiotensin- aldosterone system.

Hepatorenal syndrome progress over days to weeks after the precipitating event. While initially partly responsive to volume expansion, it is ultimately refractory to all interventions except liver transplantation.

Friday, June 13, 2014

All You Need to Know About ...TIPS

Transjugular intrahepatic portosystemic shunts (TIPS) involve creation of a low-resistance channel between the hepatic vein and the intrahepatic portion of the portal vein using angiographic techniques.

The indications for TIPS include bleeding refractory to endoscopic and medical management, refractory ascities, Budd–Chiari syndrome, and hepatorenal syndromes.

The stent is expanded to a diameter that reduces the porto-sytemic gradient to less than 12 mm Hg.

TIPS is associated with post-procedure encephalopathy rates of approximately 25%, and patients with renal insufficiency are at risk for worsened renal function.

The long-term problem with TIPS is stenosis of the shunt, which is reported in as many as two thirds of patients. Most centers advocate an aggressive Doppler ultrasound monitoring program with prompt balloon dilation for identified stenosis of the stent.

REFERENCE:

Boyer TD, Haskal ZJ, American Association for the Study of Liver Diseases (2010) The role of transjugular intrahepatic portosystemp shunt (TIPS) in the management of portal hypertension: update 2009. Hepatology 51, 306.

Thursday, June 12, 2014

Rhabdomyolysis is most commonly caused by trauma but may also be due to medications, exercise, toxins, infections, muscle enzyme deficiencies or endocrinopathies.

Rhabdomyolysis is associated with elevated levels of creatine kinase. Levels above 5000 U/L are associated with acute kidney injury; and treatment is recommended above this level.

Neither mannitol nor urinary alkalinization with sodium bicarbonate have been convincingly shown to reduce the need for dialysis or mortality from this condition.

The only effective treatment seems to be aggressive intravenous fluid replacement early in the course of the disease. This may require invasive monitoring with either a central line or a pulmonary artery catheter to prevent fluid overload.

Wednesday, June 11, 2014

Lumber
Puncture Headache

Lumber puncture is a frequently
performed procedure in the ICUs. One of the nagging problem is post-lumbar
puncture headache.

Lumbar puncture headache is believed to
result from leakage and depletion of cerebrospinal fluid, causing traction on
or distortion of anchoring pain-sensitive structures in the brain resulting in
orthostatic headache. There may also be an effect of physical changes in the
cerebral veins and venous sinuses.

According to the results of a small
study, IV theophylline promptly relieves the common problem of headache after
lumbar puncture. In the study, mean pain scores were reduced by half within 30
minutes of treatment without adverse effects, researchers reported in a poster
presentation at the 24th Meeting of the European Neurological Society (ENS).

Researchers administered theophylline,
200 mg in 100 mL of IV 5% dextrose, over 40 minutes. Patients in a sitting
position reported pain on a 10-point visual analogue scale (VAS) at time 0 and
at 30 and 60 minutes after the beginning of the infusion. All patients reported
relief of pain at 30 and 60 minutes, with the greatest percentage decrease seen
at 30 minutes.

Tuesday, June 10, 2014

Ischemic bowel is a very rare complication of EN but has been reported in critically ill patients and can be fatal. Therefore the general recommendation is that EN be avoided in patients who are in shock and in those patients in whom resuscitation is active, vasopressors are being initiated, or vasopressor doses are increasing.

Once patients are resuscitated and hemodynamically stable, EN may be initiated, even if they are receiving stable lower doses of vasopressors.

However, special attention should be paid to signs of enteral feeding intolerance such as abdominal distention or increasing gastric residual volumes.

Monday, June 9, 2014

A 0.9% solution of saline is isotonic
and is therefore called physiological or “normal.” The fluid contains a marked
surplus of chloride ions and no bufferand, hence, infusion of 2 liters or more of the fluid causes
hyperchloremic metabolic acidosis.

In adults, normal saline should be
reserved for patients with hypochloremic metabolic alkalosis, as in disease
states associated with vomiting. The fluid has a more accepted role for
perioperative fluid therapy in children where the risk of subacute hyponatremia
is a more serious concern than in adults.

When infused in healthy volunteers
normal saline might cause abdominal pain, which is not the case for lactated
Ringer’s. The fluid also has more undesired effects, including acidosis, when
used during surgery.

Normal saline is excreted more slowly
than both lactated and acetated Ringer’s solution , increasing the volume
effect (“efficiency”) of the fluid to be about 10% greater compared with the
Ringer’s solutions.

Sunday, June 8, 2014

Saturday, June 7, 2014

Q:Treatment of which infection found to show improvement in Idiopathic thrombocytopenic purpura (ITP)?

Answer: Helicobacter pylori

Interestingly, for mechanism not fully understood, particularly in adults who lives in areas with a high prevalence of Helicobacter pylori, diagnosis and treatment of Helicobacter pylori infection has shown to improve platelet counts in many patients.

Friday, June 6, 2014

Delirium is common in mechanically ventilated patients in the ICU
and associated with short- and long-term morbidity and mortality. The use of
systemic corticosteroids is also common in the ICU. Outside the ICU setting,
corticosteroids are a recognized risk factor for delirium, but their
relationship with delirium in critically ill patients has not been fully
evaluated. We hypothesized that systemic corticosteroid administration would be
associated with a transition to delirium in mechanically ventilated patients
with acute lung injury.

Delirium evaluation was performed by trained research staff using
the validated Confusion Assessment Method for the ICU screening tool. A total of
330 of the 520 patients (64%) had at least two consecutive ICU days of
observation in which delirium was assessable (e.g., patient was noncomatose),
with a total of 2,286 days of observation and a median (interquartile range) of
15 (9, 28) observation days per patient. These 330 patients had 99 transitions
into delirium from a prior nondelirious, noncomatose state. The probability of
transitioning into delirium on any given day was 14%. Using multivariable Markov
models with robust variance estimates, the following factors (adjusted odds
ratio; 95% CI) were independently associated with transition to delirium:

administration of any systemic corticosteroid
in the prior 24 hours (1.52; 1.05–2.21).

Conclusions:

After
adjusting for other risk factors, systemic corticosteroid administration is
significantly associated with transitioning to delirium from a nondelirious
state. The risk of delirium should be considered when deciding about the
use of systemic corticosteroids in critically ill patients with acute lung
injury.

Wednesday, June 4, 2014

Q:What is
twiddler syndrome?

Answer:

Twiddler's syndrome is a known
complication of pacemakers. It occurs when a patient manipulates and rotates the
pulse generator that it results in lead dislodgment, diaphragmatic stimulation
and loss of capture. Its incidence is higher than as thought, around 0.07-7%. Possible causes include elderly age group, obesity, female gender, psychiatric
illness, and the small size of the implanted device relative to its pocket. Most
dramatic effect beside failure to pace is diaphragmatic contraction by phrenic
nerve stimulation, vagus nerve, pectoral muscle, or brachial plexus stimulation
resulting in rhythmic arm twitching.

Although originally described with
pacemakers, the condition is also reported with implantable
cardioverter-defibrillators.

Tuesday, June 3, 2014

Q:What are the
2 types of Amiodarone Induced Thyrotoxicosis (AIT)?

Answer:

Type 1 - Which usually affects patients
with latent or previously known thyroid disorders and is more common in areas of
low iodine intake. It is caused by iodine-induced excess thyroid hormone
synthesis and release.

Type 2 - occurs in patients with a
previously normal thyroid gland and is caused by a destructive thyroiditis that
leads to the release of preformed thyroid hormones from the damaged thyroid
follicular cells.

Clinical Significance:Type 2 thyrotoxicosis may respond to course of glucocorticoids,
which has membrane-stabilizing and anti-inflammatory effects, as well
as glucocorticoids reduce conversion of T4 to T3. Dose is prednisone to start with 30-40 mg/d and taper over a
couple of months until free T4 levels are within the reference range. Patient
symptoms may biochemically and clinically improve within 1 week following the
start of therapy.

Monday, June 2, 2014

Nebulized lidocaine appears to be well tolerated and effective in the treatment of intractable cough particularly near the end of life. One advantage to nebulized lidocaine is the lack of significant side effects. Patients can be given 5 mL of 2% lidocaine solution with 4–6 L/min oxygen until completion of the nebulized therapy, typically over 3–5 minutes. Patients should be encouraged to maintain head elevation for at least 30 minutes post treatment and to refrain from eating or drinking for 40 minutes after the treatment completed.

Sunday, June 1, 2014

Q: Nurse called you to evaluate an intubated patient, who is desaturating. Patient is admitted for community acquired pneumonia and required intubation. Patient is on FiO2 100% and PEEP of 7. You decided to slowly increase PEEP to get saturation more than 90%. As you increase PEEP progressively to 13, patient starts coughing. Is this a good sign or a bad sign?

Answer: Good sign

Any lung recruitment maneuvers followed by cough is a good sign. This is a good sign resulting from expansion of collapsed lung.